Digital Ink: Leaving a Mark on Medicine

The Ancient Indians were the first to use pens around 5000 BCE. While these writing implements were primitive, typically consisting of hollowed out reeds that could hold a small amount of ink, which was generally soot in water with a plant gum binder, they were used for thousands of years and are still used today in certain parts of Pakistan. Around 500 BCE, pens started to be constructed from the wing feathers of larger birds, such as geese or swans. These pens, known as quill pens, were widely used until steel-nib pens were developed in the 1800s. Today, the most commonly used pen is the retractable ballpoint pen, the type often distributed by exhibitors at medical conventions or by local businesses. Being so widely available, and often free, pens are largely considered dispensable these days. While it is hard to imagine pens evolving much further, tech companies have envisioned pens with digital capabilities for decades. This year has been particularly exciting for the digital-pen tech sector, with many touting unique advancements yet reasonable price tags, making them more appealing to consumers. Digital pens are also finding a place in the healthcare sector, where they will no doubt increasingly leave their mark.

Examining Digital Pens

There are two types of digital pens: those that come with tablet PCs and function as an input device and the stand-alone digital pen, which has been around since the late 1990s when Anoto (www.anoto.com), a Swedish company, pioneered a paper that would allow a pen with a built-in camera to track itself. Stand-alone digital pens have come a long way since then. Let’s look at three of the available options and their features.

Livescribe 4GB Pulse Smartpen

This October, Livescribe released the Livescribe 4GB Pulse Smartpen (this pen was included in our Holiday Buying Guide last month), which contains “Pulse,” a small computer that captures handwritten notes while simultaneously recording audio, allowing them to be linked together. The user can tap on a note with the Livescribe Smartpen and can hear the conversation play back from the exact moment the note was written. One reviewer on Amazon.com commented that “the recordings are great, even in a large room,” whereas another said “audio quality is superb in small classroom settings; however, open wide to a large lecture hall and forget it.” Notes can be uploaded to a computer for storage, allowing keyword searches to be conducted and the notes to be shared with others. Another reviewer commented, “Another cool feature is the ability to upload your notes to a special location so that they may be shared with others—I’ve already tried doing this [as a test] with someone I know who is not very technologically savvy and, again, the results were very cool!” The Livescribe 4GB Smartpen holds approximately 400 hours of recorded audio and provides enough storage for apps to be added to the pen. Livescribe launched its Applications Store in November, which features several entertainment, education, and productivity tools, ranging from free to $99.99. The pen has a 4-star rating (out of 5) on www.amazon.com and retails for $182.99.

Logitech io2 Personal Digital Pen

The Logitech io2 digital pen resembles and feels like a regular ballpoint pen; there are no keys to press and no display. The pen is activated by removing the cap and deactivated by replacing the cap. The user writes on digital paper, as on regular paper. The pen has an ink cartridge so written or drawn notes are visible; however, the pen records all strokes with its optical sensor, and once the pen is placed back in its cradle, the notes can be downloaded to a PC. The io2 can store up to 40 pages of handwritten content, with each page defined as 29 lines of handwritten text, before the user needs to dock the pen into its cradle to offload the data. The io2 comes with free software that learns the user’s handwriting, including tables, shapes, and charts, allowing them to be turned into digital text that can be edited and used in any application. The pen has a 3.5-star (out of 5) rating on Amazon. One user commented, “The reason I like this so well is that I don’t have to take my laptop to meetings, and when I get an idea, I can just write it down as I always did.” Like the Livescribe pen, the Logitech pen also requires the use of special paper, which can be pricey. The io2 retails for $129.99 at www.amazon.com.

IOGear Mobile Digital Scribe GPEN200N

Unlike the Livescribe and Logitech digital pens, the Mobile Digital Scribe captures notes or drawings written on any surface, eliminating the need for special paper, and stores them in its receiver. The user simply writes notes on regular paper with the Mobile Digital Scribe, which uses ordinary ink refills, and then offloads them onto a laptop at a time that is convenient. Notes can be exported in JPEG format, allowing them to be shared with others via e-mail or instant messaging. The pen comes with handwriting recognition software (OCR software), which turns handwritten text into digital text. The Mobile Digital Scribe has a 3.5-star (out of 5) rating on www.amazon.com and retails for $49.99. Unlike other digital pens, this pen works with Mac OS in addition to PCs. One drawback is that the receiver must be clipped to the paper that is being written on. One Amazon reviewer commented, “I agree with the reviewer who complained about the small spring-loaded clips which are meant to secure the ‘receiver’ to one’s paper. Securing the ‘receiver clip’ to the paper is important because even a slight movement of the paper in relation to the receiver can mess things up.”

Digital Ink in Medicine

Medicine is moving into a digital age, with a great push toward replacing paper records with electronic health records (EHRs). Digital pens may eventually serve as an integral component of EHRs, and several companies are offering digital pens as EHR components or as a workflow solution that can be integrated with an existing EHR or practice management system. Digital pens are also being used in certain medical settings and can be useful to both physicians and patients. Let’s examine some of the ways digital pens are being used in medicine.

Clinical Applications

Digital pens have largely been applied clinically in Europe. During MEDICA 2009, which took place in Düsseldorf, Germany, from November 18 to 21, a new telemedicine solution called DiabCareOnline from Germany’s Ontaris was highlighted. This solution used a blood glucose meter, patient diary, Anoto digital pen, and a mobile phone to enable faster communication of patient data. Patients monitored their blood glucose levels as before and recorded them in their diaries using the Anoto digital pen. The data were then transmitted via a mobile phone to the patient’s EHR and compared with the patient’s specific blood glucose targets. Anoto officials noted that this method allowed health issues to be addressed much more quickly and lowered the cost of care because much of the data analysis was handled remotely, which also allowed patients to spend more time away from the doctor’s office.

Digital pens have also been used to assess pain. In 2008, an article by Swedish researchers published in the International Journal of Medical Informatics (www.ncbi.nlm.nih.gov/pubmed/17363323) reported on the use of a pain diary, digital pen, and mobile Internet technology to assess pain in 12 palliative home care patients between December 2002 and September 2003. On a Visual Analogue Scale (VAS) for pain, patients reported an initial pain level of 35 mm or greater on a scale of 0 to 100 mm. Patients were instructed to record their pain intensity and the number of consumed extra doses of analgesics three times daily. Additional data were collected from interviews with patients and their families, questionnaires, medical records, and the system log. Overall, patients found the pain diary and digital pen easy to use for pain assessment, and the researchers noted that contact between patients and their caregivers improved, leading to an increased sense of security among patients. In addition, an assessment of the patients’ medical records showed a quick response to variations in their health status by means of changes in medical treatment.

It is not difficult to envision digital pens eventually being used to monitor side effects experienced by patients enrolled in clinical trials or to assess pain or side effects in those receiving cancer treatments. In many cases, side effects are the No. 1 reason for discontinuing treatment. If clinicians become aware of side effects earlier, strategies to minimize or eliminate them can be implemented sooner, which may allow patients to continue to receive treatment. While no trials in patients with cancer are currently applying digital-pen technology, one observational study being conducted in the United States is assessing the use of this technology to develop individual education plans (IEPs) for people with autism spectrum disorders (http://tinyurl.com/yarypsm). The researchers plan to use the pens to collect behavior data, chart progress, create forms, and facilitate communication within the IEP team. The investigators hypothesize that a digital pen- based system will facilitate educating children on the spectrum, while enhancing communication between schools and families and saving time and money in the process by eliminating cumbersome paper-and-pencil methods of developing IEPs.

In France, digital pen technology has been used to reduce the amount of time it takes for patients to receive mammogram results (www.medicalnewstoday.com/articles/123750.php), which has also cut down on the time other women must wait to receive breast cancer screenings. Although women who had mammograms that were positive for breast cancer received notice quickly, those with negative results had to wait 3 or 4 weeks to receive notifi cation because French law requires negative screenings to undergo a second expert review. By using digital-pen technology, the expert reviewers had access to the examining radiologist’s notes while assessing the mammograms, and facilities were able to process the results of the examinations more quickly. Through the use of digital-pen technology, screening centers in France have been able to meet the legal requirement of sending out results of breast examinations within 2 weeks.

EHRs and Workflow Solution

Although healthcare is increasingly becoming digitized, many key processes remain ideally suited to paper. Several companies offer digital-pen services that allow physicians to continue to use paper forms, but also enable these forms to integrate instantly and seamlessly into existing EHR software. This allows healthcare professionals to populate these systems with timely data, which has been a challenge for many. Because using a digital pen is just like using a standard pen, there is no new technology for users to get used to. The time it takes to transfer clinical and other patient data to the EHR is also greatly reduced, and the risk of incorporating any errors is minimized. It is estimated that data re-entry can add 2 or 3 hours to the workload daily, reducing time that could be spend with patients.

Conventions and Meetings

Convention halls can be huge and tiresome to navigate, especially when you start toting all the paper and other items that get picked up along the way from the medical society, exhibitors, and others. Because digital pens are so compact and lightweight, they can be carried more easily to convention halls and meetings than laptops, which could remain at the hotel or in the office. The notes could then be off-loaded upon returning to the hotel or at a time that is convenient. If the user prefers to record sessions, Livescribe offers digitals pens that also serve as an audio recorder—the 4GB model (described earlier) and a 2GB model that holds 200 hours of recorded audio—which would allow any notes to be linked with the audio. If a particularly important session is recorded, the fi le could be shared with colleagues who may not be in attendance or who may have had to attend a different session.

The Future of Digital Pens

While digital-pen technology has not taken off yet among the masses, there is little doubt that it eventually will, especially as the technology continues to improve and its cost decreases. The healthcare sector is especially well-suited to making use of this technology, especially as incentives are offered to migrate to EHRs. While populating EHRs may be cumbersome and time- consuming, requiring considerable data entry, digital pens may help bridge the gap between paper and electronic records by converting paper documentation into digital information. Patients may eventually complete their medical history and other forms using a digital pen, and healthcare providers may use digital pens to make notes in patient records, record encounter

data, write prescriptions, and more.

Digital pens have also shown promise in improving patient care. European studies have shown that digital-pen technology may help treatment by making healthcare providers aware of important patient information in a timely fashion, such as blood glucose levels or pain levels, allowing them to act on this information more quickly. While no studies have been conducted assessing the use of digital pens to improve the care of patients with cancer, it is reasonable to conclude that this technology could have a positive impact in this population as well. Technology will continue to progress, and as it does, this platform’s mark will become more pronounced.